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ELECTRICAL-INSPECTOR RECORD
<br />APPROVALS DATE ID/SIG.COMMENTS
<br />Site-Work
<br />Underground
<br />Light Standards
<br />Spas, Pool, Fountains
<br />Sions (monument)
<br />Lile Safety /Low Voltaqe
<br />Fire Alarm / Dampers
<br />Communications Cable
<br />Building
<br />Under Slab / Floor
<br />Bonding / Grounding / UFER
<br />Transformers
<br />Torqueino
<br />Sub-Panels
<br />Air Conditioners
<br />Roof Top Equipment
<br />Factory Wired Unit
<br />Walls (Conduit)
<br />Walls (Rouoh)
<br />Ceilings (Hard & Soffit Rouqh
<br />Ceilings (T-Bar Rouoh)
<br />lA
<br />Rough 6-21'lt ,k W",t)
<br />Service lvleler U (.1\
<br />FINAL v x.w10
<br />Notes, Remarks, Etc \:7
<br />I}WNER BI III,DN:R DI]I-(:ANATII)N
<br />I h.rcby rflirm u.dcr ,'.nohy of periury rhal I !m.r.nl,r frcm lnc Conlracror' t,iccn* ljw fo, rhc followins rcas,n (S* ?0ll t'
<br />Busincss and Prolssion Cod.)r Atry Ciry or Counry whicn rcqut s r tdnrir ro .on{fl.r, nlt.i nDprovc, dcmlish ry Ennir 3n}
<br />(rudurc, Fitr ro ns nsuarcc, als rcqutcs lhc applica lor such Firtrir ro filc a stncrl (alcmnl rh.r lt o. rhc iq li....cd purfl,nr
<br />ro rhc nn,vhiiri.lrlr Conr&r.as Lienscd Law iChafler 9. Conm.n.ing wirh sc.rion 7o(D of Divhion 3 of rhc Ausinc$ rnd
<br />PoLsio.sCc'dc)orrhallIorshciscrcrrrrhcrcfmmsndlhihasislorrhcalLScdcrcmprion.AnyviolarionolSccrionT().ll5hy!n,
<br />{'Iliconl for 0 pcflnit subjNls lhc applicrnl ro uciviltcMllyolnol nmrclhan fivc hrndrcd dollar ($500)
<br />I. * own r of lhr ltr.lEdy. or ny cnlpb)rrr wilhwr!.\a\Ihcn vnc cunrF.nsdion. willdo lhe work l1dth. strudw i! nol
<br />inrcd.t ororcEd lor $lc (5(.'7044. Ausim$and Pmfc$io.s C.nc: ThcCo rerois Lienre tiw de\ nor lpply io an osfti or
<br />rlr pftrrny who builds or ihpr.vcs rh.rdri, snd wh. dtos {ch Nort hinsd}for hcr$ll or rhbugh hir orh$own cmtloyccs,
<br />providcn rhar such inlnrcrcmnB m ml inlcnded or ofiurd f.r sL. ll h.pclcr rtE trildin8 or in!.mEmrr h hld wirhin om }!s
<br />olorllt)Lion. tnc ow.cr Buildcr w hnvc,E buftl. oi Jn)ling dla h. or shc dA nor tnrild or tn ow lhc lmIdy for lhc puqrsc ol
<br />-1.!souncrollhcFropcdy.amcxclusivcly.ontrmlinAwithli.ctrsdconricl('nloconshcllncpmJccr{Sc?0.r4,Bu\im*.nd ADfs*i.. C.dc:'Ihc C.nkkktr * Li..ns. Ltrw docs nor atpl, h ri ow..r ofporcdy who bnilds or imnrovcs thcrcon.
<br />aod who conrrads for such l,oj(ls wirh a ConrBcronO liccnsd !u utrr rorheConrrocrols Lie.sc laq)
<br />-l
<br />arcientpr undcr Salioo-. B. & P.C. aor lnn rc!$o.
<br />O,..r
<br />IOAK!&T:g,DIIEIIAIIAN
<br />DECLIXAIIQN
<br />I hcrcbyalfi n undcr p.nrkyolp.rjuryonc ofthc iolbwinS d..l.rations
<br />lhuv.rndwill@inrrin.C.dia{,r.orCon$nrroS.lflnruEfrrwortcsco'qc.sarion.astmvidcdforbySccrionlT0Oofrhc
<br />t!b.t Codc, lor rh. pcnn rorcc oa rhc *ork for which rh. pcrmir i\ nsucd.
<br />,l havcord willnmint0in workcs conrpctrsariotr i.sur.ncc, ns rc{uncd hy Scclion l?OO of rhc tlhor 6de. r'or rhc l,crrorroncc of
<br />rhc *ork for shi.h lhir F.mir is ks.n. My wortcB .on!.nsurion insrucc curicr ud F,licy nu mbs dc:
<br />Polkv Numbcr
<br />-ErDrr:
<br />-l
<br />enity rhlr io rhc perlorrunce orrhe *o,k r.r shi.h rhis ri.rnir h i\su.d. I shlll mr.npl,ry any p.r$tr in.ny mmRr
<br />v, * b rr..ft subF.' tu rh. workcs .o.Dcnsaln kwsorcalirorni(.nd l8e.rharill should hcdom suhjcd lo rl'c
<br />wotlec smp.nsl ion pbvisions ol ssriotr 3700 .l lh. tjho. Codc. I shall, lonhsirh omDly wirh tho$ F)vtion\
<br />WARNINCj Fiilur. ro surc qorkcn omncn\rrio. corraSc is u,l,wtul. and shrll \uhFl !n cmplorcr ro dmin,l pcMlrics ud
<br />crvil lincs trf to otrc hundrcd rhousrM do ($l(x).()(x)), ir iddilion ro lhc co( ofcomrcnsnrion-
<br />Sc.rio01076 ofrhc Lat r Codc, inrcrcst and
<br />I hc.chj- rllnmukl., Fnxhyol trrj yrl,rr l rN ll.ctrwl u vnnnr ol Cl pror 9 (.ontrnc ctrrF qih Sc.{i(r r(x)l)r !l l)ivi!it :l
<br />of thc BusiNssaM Prulcssions Codc. rxl my licctrs n in iullioiccatolcft\.'l
<br />t bu(r(
<br />I hcrcby al6rn undcr Fnallyofpcrjury rhar I
<br />issucd (S...l097.Civ. C ).
<br />hn lcndins ngeky ror ihc p.rrurmRc.lrhc work rbr which lhn rirnit k
<br />APILICANIDECI.AXAIIO!
<br />I trEhy damr unds p..ally ol lErjury om oflhc lolloeing dslmlionsl
<br />Dc'ftlirn,. Pqmns Asbr{os N.rifi.drnrn Fcd.rnl R.Suhri.ns Onb 40, P.n6)
<br />R.quncd hlt.rof Norifi cainn
<br />'rgul ri(rN rc!rrtli',! rn{ro\rdnnnrlxrc nor rft,l'.xhl( n) rhi: I'hlc(r
<br />rcad thh.p/i.arion atrd olc rh.rh. abvc irbrnrnr ion k concd I asre lo ompl, wirh lll Cir, rid Counry
<br />b bxrldin! .orl{fl.rion. .Jri hd.by iurlxtrizc ircs oilhis Citr ond Couniyb cnlcr rF,o rh.
<br />L'b'\n
<br />c.-
<br />Pole Bases
<br />lVleter Release
<br />7-Zo'4
<br />l-irctrsc Nutr{rr
<br />tf,ndcr's Ad.($:
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